What is the percentage of patients who experience bleeding after gastric polypectomy?

Bleeding Risk in Gastric Polypectomy

Gastric polypectomy is associated with a bleeding risk of 0.2% to 8% of procedures, similar to the bleeding risk seen with colonoscopic polypectomy. 1

Incidence of Bleeding in Gastric Polypectomy

• Bleeding complications from gastroduodenal polypectomies have been reported in 0.2% to 8% of procedures 1
• A specific study examining gastric polypectomy found a 7% risk of bleeding after endoscopic resection of gastric polyps 2
• This bleeding risk is comparable to colonoscopic polypectomy, which has a reported bleeding rate of 0.4% to 3.4% 1

Types of Bleeding After Polypectomy

Polypectomy can result in two distinct types of bleeding:

• Immediate bleeding: Occurs during the procedure and can usually be controlled endoscopically 1

  • More common with cutting or blended electrical current 1
  • Typically arterial in nature from inadequate hemostasis of blood vessels in the polyp stalk 1
  • Can generally be controlled by resnaring the stalk and applying pressure 1

• Delayed bleeding: Occurs up to 15-30 days after the procedure 1

  • Results from sloughing of the eschar at the polypectomy site 1
  • Usually self-limited and resolves with supportive care in more than 70% of cases 1
  • Presents as passage of large-volume bloody bowel movements 1
  • More common with coagulation current, which creates deeper ulcers at the polypectomy site 1

Risk Factors for Bleeding After Gastric Polypectomy

Several factors increase the risk of bleeding after polypectomy:

• Polyp characteristics:

  • Large polyp size (≥10 mm) significantly increases risk (adjusted OR: 4.5; 95% CI: 2.0-10.3) 1
  • Sessile polyps greater than 2 cm in diameter bleed more commonly 3
  • Proximal location (for colonic polyps) 1

• Patient factors:

  • Advanced age 1, 3
  • Male sex 1
  • Comorbid conditions including hypertension, diabetes, coronary artery disease, and chronic obstructive pulmonary disease 1
  • Use of anticoagulants or antiplatelet medications 1, 4, 5

Prevention of Bleeding

Several techniques can help reduce the risk of bleeding:

• Technical considerations:

  • Use of blended rather than pure cutting electrocautery currents in polypectomy snares can reduce early bleeding risk 1
  • Cold snare or cold forceps removal of small polyps has lower bleeding risk than hot biopsy techniques 1
  • Prophylactic placement of hemostatic clips can reduce bleeding risk, particularly for large polyps or those in high-risk locations 6
  • Injection of epinephrine prior to polypectomy can reduce bleeding risk 6

• Pre-procedure assessment:

  • Endoscopic ultrasound (EUS) before polypectomy has been studied but does not appear to significantly contribute to the safety of the procedure 2
  • However, for large polypoid lesions, EUS examination of the pedicle may help document the size of vascular structures before endoscopic transection 7

Management of Polypectomy Bleeding

When bleeding occurs, several management strategies are effective:

• For immediate bleeding:

  • Injection of 1:10,000 epinephrine followed by multipolar cautery or clipping 1
  • Resnaring the stalk of the polyp and applying pressure 1
  • Bipolar coagulation or heater probe application (power settings of 16-20 W for bipolar or 15-20 J for heater probe) 1

• For delayed bleeding:

  • Loop ligation of remaining polyp stalk 1
  • Endoscopic band ligation 1
  • Injection of adrenaline followed by thermal therapy 1
  • Application of endovascular clipping devices 1

Special Considerations

• Anticoagulated patients:

  • Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate when prophylactic clips are applied 5
  • NOACs (non-vitamin K antagonist oral anticoagulants) are associated with a higher risk of post-polypectomy bleeding compared to warfarin 4

• Monitoring:

  • Most patients with post-polypectomy bleeding can be managed without intensive care monitoring 3
  • Advanced age appears to be predictive of transfusion requirement 3

In conclusion, while gastric polypectomy carries a notable risk of bleeding (0.2-8%), understanding the risk factors and employing appropriate preventive and management strategies can help minimize complications and improve outcomes.